18.1 Low Back Pain and the Evidence for Effectiveness
of Physical Therapy Interventions
Table of Contents

LUMBAR ANATOMY AND PHYSIOLOGY

Abstract:

CONTENT: In this monograph, Dr. Bishop successfully integrates functional anatomy with clinical application to justify the need for clinicians to have a strong working knowledge in gross anatomy. Areas covered include contractile and noncontractile tissues and a thorough review of disk morphology and its response to trauma. Common anatomic pain generators are also discussed. Review questions at the end of the monograph serve to highlight the relationship between structure and clinical findings. This monograph will enable course participants to refresh their anatomical knowledge and improve their diagnostic skills in the evaluation and treatment of patients with low back pathology. CASE ANALYSES: Three case studies are presented. The first case is a 32-year-old man with complaints of central low back pain without radiation into the leg. The second case is a 65-year-old woman with complaints of pain in the right buttock and posterior thigh and calf. The final case is a 27-year-old woman with left calf and leg pain.

Keywords:​

spine, kinesiology, low back pain

References:

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DIAGNOSTIC IMAGING IN PHYSICAL THERAPY MANAGEMENT OF LOW BACK PAIN

Abstract:

CONTENT: Dr. Biederman introduces the reader to the various technologies used in imaging studies for the evaluation of low back pain. Common pathologies are then cited, including degenerative disk disease, disk herniation, spondylolysis, and spinal stenosis. An understanding of the role of imaging in the evaluation and treatment of low back pain is imperative to establishing proper treatment planning. After reading this monograph, you will gain an understanding of the nomenclature and findings from imaging studies and will be better suited to effectively communicate with radiologists and referring physicians to coordinate patient care. CASE ANALYSES: Three case studies are then presented to familiarize the reader with the role of imaging in patient management. The first case is a 53-year-old man with an otherwise unremarkable medical history who is referred to physical therapy with a chief complaint of pain at the right hip, lateral thigh, and leg, and numbness at the bottom of the right foot between the third and fourth toes. The second case an active 72-year-old man self-referred to physical therapy who complains of pain at the outside of the right hip exacerbated by sitting and bicycle riding. The final case describes a 14-year-old adolescent boy referred by his primary care physician to your office for evaluation and treatment of low back pain.

Keywords:​

spine, radiology, lumbar

References:

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LUMBAR EXAMINATION AND ASSESSMENT

Abstract:

CONTENT: In this monograph, Mr. Jefferson addresses nonmusculoskeletal and musculoskeletal sources of low back pain and specifically discusses a number of common pathologies and their distinguishing clinical presentations. He then reviews the essential components of a thorough examination process. This section includes the importance of systems review and the use of questionnaire data. A well-summarized section on current objective tests and measures focuses on effectively assessing patient movement patterns and understanding the link between pain and dysfunction. A separate section on reliability and validity of evaluation of sacroiliac joint pathology is also presented, as is a separate section on recognizing and quantifying chronic pain. Mr. Jefferson then discusses the role of clinical prediction rules and patient classification schemes. The information in Mr. Jefferson's work will provide yet another vital piece of clinical expertise to help therapists effectively solve the clinical perplexities and challenges that often accompany patients with low back pathology. CASE ANALYSES: Three unique case studies conclude the monograph and serve as applied examples of the author's clinical reasoning in dealing with various patient scenarios. The first case is a 36-year-old engineer with a 2-week history of left-sided back and buttock pain following an extended amount of time doing yard work. The second case is a 23-year-old university student with a 1-month history of right-sided buttock and leg pain. The final case is a 76-year-old gentleman with a 3-week history of right leg pain and weakness in his right foot.

Keywords:​

spine, evaluation, diagnostic

References:

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PSYCHOLOGICAL SCREENING AND MANAGEMENT OF THE PATIENT WITH LOW BACK PAIN

Abstract:

CONTENT: Dr. George shares his expertise in the area of psychological screening and intervention strategies for the patient with low back pain. The theoretical construct of the Fear Avoidance Model of Musculoskeletal Pain is described and the reader is made aware of psychological factors that exist in patients with low back pain. By using an evidence-based approach, the reader will be well-suited to apply the information and be able to make modifications in treatment planning for patients with acute and chronic low back pain. Dr. George concludes the monograph by discussing potential future directions of the Fear Avoidance Model and the need for studying other measures such as pain-related fear and pain catastrophizing. After reading this monograph, you will be provided with a unique perspective on how psychological factors influence all phases of patient care in the area of managing low back pain. This most certainly will lead to greater success in treating your patients who have low back pain. CASE ANALYSES: The monograph also includes 2 excellent case studies. Case study 1 is a 42-year-old man referred to physical therapy for examination and treatment of acute lumbosacral strain. Case study 2 is an example of a case that emphasized a graded exposure approach to management of a patient with low back pain. The patient is a 21-year-old man referred to physical therapy for examination and treatment of low back pain.

Keywords:​

rehabilitation, fear avoidance, lumbar

References:

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LOW BACK TREATMENT-BASED CLASSIFICATIONS

Abstract:

CONTENT: The authors explain the justification for using a classification approach to evaluate patients with low back pain and also to serve as a guide to developing the most effective treatments in the areas of exercise, modalities, and manual techniques. Clinical prediction rules are discussed based on current research evidence, and outcome measures are reviewed to accurately capture patient improvements and treatment efficacy. The last section of the monograph specifically discusses screening for red flags and obstacles to recovery. There is also a brief discussion of low back pain in children and adolescents. After reading this monograph, you will gain an appreciation of using a classification-based approach and understand the role of clinical prediction rules in the development of classification-based treatment strategies. Furthermore, the authors thoroughly cover the examination process and treatments, including manipulation, exercise stabilization, and traction. The high incidence of low back pain makes the information covered in this monograph an essential reference for treating patients with this pathology. The entire monograph should enable you to perform a critical analysis of how to evaluate and treat patients with low back pain. CASE ANALYSES: To facilitate comprehension, thought-provoking review questions written in a case-based format conclude the monograph. The first case is a 29-year-old woman with a primary complaint of low back pain that is exacerbated during recreational activities. The second case is a 49-year-old man who fell approximately 3 months ago when he attempted to lift a rock while building a stone wall and felt a sharp pain in his low back. The third case is a 35-year-old woman office assistant who injured her back while lifting a box of paper.

Keywords:​

rehabilitation, lumbar, outcomes

References:

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LUMBAR INTERVENTIONS

Abstract:

CONTENT: Drs. Cook and Learman use a best evidence approach in discussing levels of evidence for interventions used in treating lumbar pathology. The authors present a thorough review of common modalities used in treating low back pathology including ultrasound, electrical stimulation, laser therapy, traction, and exercise therapy. The strength of their work is their detailed analysis of providing the reader with a complete description and review of exercises that should be part of a lumbar stabilization program. The efforts by Drs. Cook and Learman represent a vital link in providing the reader with an effective summary of the literature in determining the most effective treatments for lumbopelvic pain. Through their expertise you will be able to apply evidence-based principles as part of your personal quest toward providing high quality care to your patients who often feel at the mercy of low back pain. CASE ANALYSES: The first case is a 23-year-old man employed as a pipe fitter whose job requires significant physical strength and who has suffered reoccurrence of low back injury. The second case describes a retired 63-year-old woman who was previously employed as a hairdresser who serves as sole caregiver for her elderly mother. While providing physical assistance to her mother for basic activities of daily living she complains of intermittent low back pain that exacerbates to severe groin and posterior thigh pain.